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Emergency Department Crowding – A Literature Based Review
Prepared by:Neil Roy, MD
Christiana Care Health Services EM1
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• Current literature
• Causes of crowding
• Explore the most efficient solutions
• Future goals
Overall Objectives
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Overview
• Causes of ED Crowding– Input Factors
• What brings patients into the ED
– Throughput Factors• Bottlenecks within the ED
– Output Factors
• Obstacles outside the ED
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Overview
• Effects– Adverse Outcomes
• Patient Mortality
– Reduced Quality• Transport Delays• Treatment Delays
– Impaired Access• Ambulance Diversion• Patient Elopement
– Provider Losses• Financial Effects
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Overview
• Solutions– Increased Resources
• Additional Personnel• Observation Units• Hospital Bed Access
– Demand Management• Non-urgent Referrals• Ambulance Diversion• Destination Control
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Definitions
• Ambulance Diversion: – Ambulances are diverted to other, less-crowded
hospitals
• Inpatient Boarding:– Patients remain in the ED after already being
admitted to the hospital
• Destination Control:– Use of internet-accessible operating information to
redistribute ambulances
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Causes: Input Factors
Non-Urgent Visits• Definition: Low-acuity ED patients seeking care
in the ED.– Present even in hospitals with dedicated fast-track
systems.– Reasoning: Typically insufficient access or/and
untimely access to primary care.
• Account for a small portion of total ED volume.
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Causes: Input Factors
Frequent Flyers• Definition: 4 or more annual visits to the ED
– Responsible for 8-14 percent of the total ED visits – Often non-urgent complaints – This includes: Chronic illness, drug seeking patients,
malingers
• However, among these patients a good portion frequently have serious pathology.
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Causes: Input Factors
Sudden influx in ill patients
Example: Influenza Season– Los Angeles county hospitals recorded a four fold
increase in ambulance diversion compared to other times of the year.
– 100 local cases of flu then resulted in an increase of 2.5 hrs per week of ambulance diversion.
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Causes: Throughput Factors
• Definition: Throughput factors are intra-emergency departmental obstacles
• Average Nurse: Cares for 4 patients simultaneously
• Average Physician: Cares for 10 patients simultaneously
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Causes: Throughput Factors
• Ancillary Service Use:– Definition: Ancillary Services include ED
procedures, lab tests, and imaging modalities.
– No study has been done documenting ED wait times in comparison to the amount of studies ordered.
– However, the use of ancillary services has been shown to prolong ED length of stay among surgical critical care patients.
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Causes: Output Factors
• Inpatient Boarding:– Half of American ED’s have extending
boarding times.
– A point-prevalence study indicates that 22 percent of all ED patients were actually boarded patients.
– In short – ED Boarding is one of the largest factors slowing a patients stay in the Emergency Department.
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Causes: Output Factors
• Hospital Bed Shortages:– Correlation between ED treatment time and
hospital bed occupancy well documented.
– Specifically – when a hospitals occupancy exceeded 90 percent, ED wait times were shown to drastically increase.
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Effects: Adverse Outcomes
• Patient Mortality:– At one Australian ED, high occupancy was
estimated to cause 13 deaths per year. – A study done in Houston identified a
statistically insignificant trend in which there was a correlation between higher mortality among trauma patients and those who were admitted during trauma ambulance diversion.
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Effects: Reduced Quality
• Transport Delays:– Patient transport time increases because
crowded hospitals are forced to divert ambulances elsewhere.
• Treatment Delays:– Longer door to doctor– Longer door to needle for AMI– Delay in pain assessments
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Effects: Provider Losses
• Estimated 204 dollars lost per patient with an extended boarding time.
• Boarded patients in the ED for greater than a day stayed in the hospital longer.
– Estimated increase in 6.8 billion dollars over 3 years
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Solutions: Increased Resources
• Ways that have been shown to effectively decrease ED stays:
– A permanent increase in ED physician staffing.
– Activation of reserve personnel during peak times.
• For Example: Influenza Season
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Solutions: Increased Resources
• Observation Units: – Reduced LOS for patients with chest pain and
asthma exacerbation.
• Acute Care Units (ED managed):– Reduced ambulance diversion by 40 percent. – Decreased boarded patients from 14 to 8
during a 2 year period.
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Solutions: Increased Resources
• Hospital Bed Access:– At one studied hospital, increasing the
number of critical care beds from 47 to 67 decreased ambulance diversion by nearly 66 percent.
– During the past decade, emergency department visits have increased by 26%, while the number of emergency departments has decreased by 9% and hospitals have closed 198,000 beds (View Graph).
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Solutions: Increased Resources
Kellermann AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28;355(13):1300–1303.
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Solutions: Increased Resources
• Point-of-care Laboratory Testing:
– Shown to decrease length of stay by 41 minutes.
• Improved ED Ancillary Service Staffing:
– Shown in numerous studies to increase efficiency, and decrease wait times.
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Solutions: Demand Management
• Non-urgent Referrals:
– 38 percent would swap their ED visit for a primary care appointment within 72 hours.
– 94 percent of patients who were referred to a community based care center reported their conditions were better or unchanged.
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Solutions: Demand Management
• Destination Control:
– Use of internet accessible operating information to redistribute ambulances.
– Physician directed ambulance destination control reduced ambulance diversion by 41 percent.
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Discussion
• Not Causes for ED crowding:
– NOT because of non-urgent visits
– NOT because of frequent-flyer visits
• Main Causes for ED crowding:
– Inpatient boarding
– Other hospital related factors
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Discussion
• Most Beneficial Interventions:
– Alter operation of the hospital
– Community services
– Not altering the ED itself
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The Next Step?
• Scarcity of Randomized Control Trials:
– Why? Because ED operational changes typically involve the entire department rather than individual patients that can be randomized.
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The Next Step?
• Ways to improve the ED further?
– Focus on ED-Hospital Integration
– Examine hospital and multi-center community networks in larger studies
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References
1. Bohan JS. Emergency Care: A System in Crisis. JWatch Emergency Med. 2006; 1-1
2. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006; 47:317-326
3. Hoot NR, Aronsky D. Systematic Review of Emergency Department Crowding. Ann Emerg Med. 2008; 52: 126-136.
4. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006; 355: 1300–1303
5. Pines JM, Locallo AR, Bast WG. The Impact of Emergency Department Crowding Measures on Time to Antibiotics for Patients with Community Acquired Pneumonia. Ann Emerg Med. 2007; 50: 510-516.
6. Pines JM, Hollander JE, Locallo AR. The Association between Emergency Department Crowding and Hospital Performance on Antibiotic Timing for Pneumonia and Percutaneous Intervention for Myocardial Infarction. Acad Emerg Med. 2006; 13: 873-878.
7. The Lewin Group. Emergency department overload: a growing crisis — the results of the American Hospital Association Survey of Emergency Department (ED) and Hospital Capacity. Falls Church, VA: American Hospital Association, 2002.